2019 Performance Requirements for 2021 Medicare Payments

2019 Performance Requirements for 2021 Medicare Payments

Medical professionals and other stakeholders have until September 10 to make a difference in the course of future healthcare reforms. Tucked into a proposed rule to update the Medicare Physician Fee Schedule for 2019, released for public inspection on July 12, the Centers for Medicare & Medicaid Services (CMS) proposes policy changes for Year 3 of the Quality Payment Program (QPP).

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) tasked CMS with strengthening Medicare access by improving clinician payments, among other things. Through this regulation, the QPP and its two tracks for participation — the Merit-based Incentive Payment System (MIPS) and Advanced Alternate Payment Models (APMs) — were born.

In this latest proposed rule with comment period, CMS continues to implement MIPS and Advanced APMs, as required by MACRA, while working to reduce the burden that adopting either track places on clinicians. Here is a synopsis of the changes CMS is proposing for Year 3 of the QPP. Evaluate the policy changes carefully and, remember, you have only 60 days from the release date to tell CMS what you think.

Low-volume Threshold and MIPS Year 3 Opt-in Policy

In working toward the goal of reducing burden, CMS is proposing to update to its “opt-in” policy, as shown in Table A. Notice that the low-volume threshold would include a “professional services” factor for 2019.

Table A: MIPS Opt-in Scenarios
Dollars     Patients     Professional Services     Eligible for Opt-in?
≤90K           ≤200             ≤200                                         No – excluded
≤90K           ≤200              >200                                        Yes – may voluntarily report
>90K           ≤200              ≤200                                        Yes – may voluntarily report
≤90K           >200              >200                                        Yes – may voluntarily report
>90K           >200              >200                                        No – required to participate

MIPS Comparison Between Year 2 and Year 3

Other than a change to the MIPS eligibility requirements, there are not a lot of surprises for performance year 2019. Several policy updates were either proposed or finalized in the 2018 QPP final rule, and are just now being finalized or implemented. Table B provides a quick view of the proposed changes to MIPS policy for the 2019 performance year.

Table B:  MIPS Year 2 and Year 3 Comparison

Year 2 (2018) Final Year 3 (2019) Proposed

MIPS Eligible Clinician Types

MIPS eligible clinicians:

·       Physicians

·       Physician assistants

·       Nurse practitioners

·       Clinical nurse specialists

·       Certified registered nurse anesthetists

MIPS eligible clinicians:

·       Same five clinician types as in Year 1 and 2, PLUS:

o   Clinical psychologists

o   Physical therapists

o   Occupational therapists

o   Clinical social workers

MIPS Determination Period

Low-volume Threshold Determination Period:

·       First 12-month segment: Sept. 1, 2016 – Aug. 31, 2017 (including 30-day claims run out)

·       Second 12-month segment: Sept. 1, 2017 to Aug. 31, 2018 (including 30-day claims run out)

Special Status:

·       Use various determination periods to identify MIPS eligible clinicians with a special status and apply the designation.

·       Special status includes:

o   Non-patient facing

o   Small practice

o   Rural practice

o   Health Professional Shortage Area

o   Hospital-based

o   Ambulatory surgical center-based

Change to the MIPS Determination Period:

·       First 12-month segment:
Oct. 1, 2017 – Sept. 30, 2018
(including 30-day claims run out)

·       Second 12-month segment:
Oct. 1, 2018 – Sept. 30, 2019
(does not include 30-day claims run out)

Performance Threshold and Payment Adjustments

·       ≥ 70 points: Up to 5% payment adjustment and exceptional performance bonus of 0.5%

·       15.01-69.99: Positive adjustment greater than 0%

·       15 points: Neutral

·       3.76-14.99: Negative payment adjustment greater than -5% and less than 0%

·       0-3.75: Negative payment adjustment of -5%

·       ≥ 80 points: Up to 7% payment adjustment and exceptional performance bonus of 0.5%

·       30.01-79.99: Positive adjustment greater than 0%

·       30 points: Neutral

·       7.51-29.99: Negative payment adjustment greater than -7% and less than 0%

·       0-7.50: Negative payment adjustment of -5%

Collection, Submission and Submitter Types

Submission mechanisms used all-inclusively when referencing:

·       Method by which data is submitted

·       Certain types of measures and activities on which data are submitted

·       Entities submitting such data

Revise existing and define additional terminology:

·       Collection Types:

o   A set of quality measures with comparable specifications and data completeness criteria

·       Submission Types:

o   The mechanism by which a submitter type submits data to CMS

·       Submitter Types:

o   MIPS eligible clinicians, groups, or a third-party intermediary

Virtual Group Elections

·       Must be made by December 31 of calendar year preceding applicable performance period, and cannot be changed during performance period.

·       Election process broken into two stages

·       Technical assistance available

Same as in Year 2, except:

·       TINs would be able to inquire about their TIN size prior to making an election during a five-month timeframe, which would begin on August 1 and end on December 31 of a calendar ear prior to the applicable performance period.

·       TIN size inquiries would be made through the QPP service center.

Quality Performance Category

·       Weight – 50%

·       Bonus Points: 2 points for outcome or patient experience; 1 point for other high-priority measures; 1 point for each measure submitted using electronic end-to-end reporting; cap on bonus points at 10 percent of category denominator

·       Data completeness – 60 percent for submission mechanisms except for Web Interface and CAHPS; measures that do not meet data completeness criteria earn 1 pt (small practices, 3 points)

 

·       Weight – 45%

·       Bonus Points: Same as Year 2, with the addition of a small practice bonus of 3 points for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure

·       Data completeness: Same as Year 2

·       Special considerations:

o   Reduce by 10 points the total measure achievement points for MIPS eligible clinicians who submit a measure significantly impacted by clinician guideline changes or other changes that CMS believes may pose patient safety concerns.

o   Reduce the total available measure achievement points by 10 points if the sample size a group reports to the CAHPS for MIPS survey is not sufficient.

·       Topped-out measures – Same as Year 2, except:

o   CMS proposes to remove measures that reach the 98th to 100th percentile range in the next rulemaking cycle, rather than the usual five-year period; and

o   QCDR measures would not qualify for the topped-out measure cycle and special scoring.

Cost Performance Category

·       Weight – 10%

·       Measures:

o   Total Per Capita Cost

o   Medicare Spending Per Beneficiary (MSPB)

·       Measure Case Minimums:

o   Case minimum of 20 for Total per Capita Cost measure and 35 for MSPB

·       Weight – 15%

·       Measures:

o   Total Per Capita Cost

o   Medicare Spending Per Beneficiary (MSPB)

o   8 episode-based measures

·       Measure Case Minimums:

o   Case minimum of 10 for procedural episodes

o   Case minimum of 20 for acute inpatient medical condition episodes

·       No improvement scoring

Promoting Interoperability

·       Weight – 25%

·       May use any combination of 2014 and 2015 Edition Certified Electronic Health Record Technology (CEHRT)

·       Performance-based scoring:

o   Comprised of a base, performance, and bonus score

o   Must fulfill base score requirements to earn a score

·       Weight – Same as Year 2

·       Must use 2015 Edition Certified Electronic Health Record Technology (CEHRT)

·       Performance-based scoring:

o   CMS would eliminate the base, performance, and bonus score and score performance at the individual measure level

o   Clinicians would have to report the required measures under each objective or claim the exclusions

·       New measures:

o   ePrescribing:

§  Verify Opioid Treatment Agreement, worth 5 bonus points

§  Query of Prescription Drug Monitoring Program, worth 5 points

o   Health Information Exchange:

§  Support Electronic Referral Loops by Receiving and Incorporating Health Information, worth 20 points

Improvement Activities
·       Weight – 15%

·       Activity weights:

o   Medium = 10 pts

o   High = 20 pts

o   Small practices, non-patient facing clinicians, and clinicians located in rural or HPSAs receive double weight and report on no more than 2 activities to receive highest score

·       Weight – Same as in Year 2

·       Activity weights – Same as in Year 2

·       Improvement Activities:

o   Add 6

o   Modify 5

o   Remove 1

·       Remove the CEHRT bonus to align with the new Promoting Interoperability scoring requirements

Misc. Proposed Changes:

• MIPS CQMs replaces registry measures
• Medicare Part B Claims submission mechanism would be limited to small practices
• CMS proposes to implement a facility-based scoring option for clinicians who meet certain criteria, beginning with the 2019 performance period. CMS finalized the policy for facility-based scoring in the 2018 QPP final rule.

Advanced Alternate Payment Models (APMs)

Here’s a quick synopsis of proposed changes for Advanced APMs in 2019:\

  • CMS would increase the CEHRT use criterion so that an Advanced APM must require at least 75 percent of eligible clinicians in each APM entity use CEHRT.
  • Effective for 2020, streamline the quality measure criteria to state that at least one of the quality measures upon which an Advanced APM based payment must be:
    • 1. On the MIPS final list;
    • 2. Endorsed by a consensus-based entity; or
    • 3. Otherwise be determined to be evidence-based, reliable, and valid by CMS.
  • Effective for 2020, amend the Advanced APM quality criterion to require that the outcome measure used must be evidence-based, reliable and valid by meeting one of the following criteria:
    • 1. On the MIPS final list;
    • 2. Endorsed by a consensus-based entity; or
    • 3. Otherwise be determined to be evidence-based, reliable, and valid by CMS.
  • Maintain the revenue-based nominal amount standard at 8 percent through 2024.
  • Allow eligible clinicians to become Qualifying APM Participants (QPs) starting in 2019 based on a combination of participation is Advanced APMs with Medicare and Other Payer Advanced APMs.

State Your Case

CMS is seeking comment under the proposed rule on the following policy items:
• Expansion of facility-based measurement to determine MIPS Cost and Quality scores based on performance for clinicians in end-stage renal disease and post-acute care settings.
• Future approaches to simplifying scoring in the Quality performance category by assigning different values to different measures and measure sets.
• Subgroup report to determine different approaches for subgroups to participate in MIPS.
• Cross-performance category measurement sets

What is Macra

The proposed rule will be published in the July 27 Federal Register. CMS will accept public comment on this proposed rulemaking until Sept. 10 at 5 p.m. Refer to CMS-1693-P for commenting instructions.

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman

About Has 613 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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